Is physician shadowing immoral?

Countless times as a patient both at two hospitals in New York City, I have witnessed doctors arrogantly waltzing into an examination room and arriving not alone but with an entourage. Like Greeks bearing gifts, they arrived with something unwanted and threatening: medical students, interns, residents, and fellows. And not once, in all the many times that I have been subjected to this ignominious practice, was my consent ever obtained prior to the doctor’s arrival.

Some would argue that this practice is perfectly acceptable provided high school students and college students are not doing the shadowing. The idea that such young students could ever be permitted to shadow a doctor is utterly ludicrous. Even if a physician wished to have a resident or fellow observe a session with a patient, should they not in good conscience be morally, if not legally, obligated to first obtain the patient’s permission?

There are hundreds of teaching hospitals in this country that serve millions of patients. Are all of these patients supposed to voluntarily relinquish all vestiges of privacy?

If a patient is denied the right to meet with their doctor in private, what rights does the patient actually have? Do they have the right to discuss their medical questions and concerns with their doctor in confidentiality, and without unwanted interlopers in the room? Do they have the right to a respectful medical examination without unwanted persons in the room violating their privacy in a base and barbarous fashion?

There are physicians who argue that it would be impossible to train the younger generation of doctors should any restrictions be placed on this practice. Yet, those who make this argument fail to acknowledge the fact that, should patients be asked, many would, in fact, give their consent.

As a photographer, I feel that it is unethical to take the portrait of a stranger without first obtaining their consent. Does it follow that I am then making the case that photographic portraiture be banned altogether?

It is this absence of consent, which can bring about a profound degradation of trust — a trust not only in the patient’s physician — but in the entire medical profession. And the ramifications of this violated trust can be extremely grave.

Many of the most enthusiastic supporters of physician shadowing ardently defend the practice, just so long as they are not the patients and on the receiving end of it. For attending physicians at these two hospitals, who love walking into an examination room with their entourage, are able to use their superior health plans to in turn meet with their own doctors in private. They are then able to avoid the very practice which they defend so vigorously in dealing with their own patients.

What does it say about the attending physician, who patronizingly and condescendingly dismisses a patient’s objections over a medical student, intern or resident observing the session? What example are they setting for the younger generation of doctors?

And will these medical students continue to defend nonconsensual physician shadowing, should there come a time when it is they who wish to meet with a doctor in private and yet are unable to do so? Will they clap their hands with glee, when it is their doctor who proceeds to enter the examination room — not alone but with another person?

Moreover, one of the principal reasons why so many doctors prefer not to be alone in the room with their patients is so that they can later have a witness to protect themselves from lawsuits. How can even the vaguest semblance of privacy and trust survive this crude and uncivilized behavior? And what will become of the doctor-patient relationship that is completely devoid of trust and mutual respect?

Despite the fact that I have repeatedly told seven different departments at the first hospital that I do not give my consent to this, they continue to invite medical students, residents, and fellows to shadow many of my doctor visits. The other hospital — where I wouldn’t bat an eyelash should a medical student attempt to follow me into the restroom to watch me relieve myself — is even worse.

Many patients are also afraid to object, because of the hospital’s authoritarian policy prohibiting patients from changing oncologists within any given department.

The dismantling of the humanities has also greatly contributed to the problem because once a young person receives an advanced scientific and technical training utterly devoid of literature, history, and art they will inevitably be sucked into a vortex of amorality.

Nonconsensual physician shadowing also paves the way for further abuses, such as medical students and residents performing pelvic and rectal exams on anesthetized patients. This is because once medical students are inculcated with the idea that the patient is a mere teaching tool, there is no turning back from this road to perdition.

The pernicious influence of so many teaching hospitals has led to the indoctrination of thousands of young health care professionals with the idea that the patient is not a human being but a commodity that has no rights. And this dogma has spread throughout the entirety of American health care like a cancer.

Following an extremely painful liver biopsy, a nurse walked in on me while I was attempting the undignified act of urinating into a flask. What remains so hauntingly ingrained in my memory is the fact that she neither left nor apologized but became angry and defensive when I asked her to leave. This behavior underscores the total moral bankruptcy of so many health care professionals that work in teaching hospitals. And her complete disdain for my privacy remains vividly ingrained in my memory, as a metaphor for the barbarism which so many patients in this country are all too often forced to endure.

Shadowing is the way we raise up the next generation of physicians. Yes, ask for permission, but if one is admitted to a teaching facility then I think it should include assumed consent to allow students and residents alongside the attending.

5ny

I’m fine with that. It’s when they have college marketing majors shadowing them because they are “considering” a career in medicine and their father/mother is friends with a doc and then they come around. That’s even ok too with me, as long as it’s disclosed and depending on the situation. The problem becomes when, for example, I strongly suspect one of these kids was introduced to me as a pediatrician. Very often, these college and high school kids who are vaguely considering a career in medicine are brought in wearing white coats and not property introduced nor is the patient consented.

NewMexicoRam

I’m talking about medical students and residents, not “wannabees.”. And there are ways to maintain dignity and respect.

5ny

I agree with you on the med students and other relevant rising professionals. I’m a counselor so I started my career shadowing and learning from sitting with counselors while dealing with students’ heavy, personal stuff. I now train others sometimes too. We definitely respect people’s privacy and dignity and have ways to do it. I have had students tell me they don’t want an observer and I absolutely honored that. I am referring to some places that seem to have a loose culture. I have a lot of exposure to a lot of stuff and I have seen some “interesting” things. This happens in my profession too. I’ve seen some social workers, counselors, etc. act like they are entitled to a student’s issues and just ask about very intimate stuff without much thought to sensitivity and/or privacy regarding who is around.

I think a few issues are being conflated here. The first is legitimate students becoming professionals. Then there are needless privacy exposures by practioners who may have a sense of entitlement and/or just aren’t that sensitive. Thirdly, there are extra staff and even outside observers that don’t need to be there but are there for themselves. For example, my friend went for a stress test. There was a nurse and 2 aides there. My friend wanted the 2 aides out because he knew they weren’t needed and he didn’t want them watching. He nicely asked them to leave and they said, “it’s no big deal, we’ve seen it all before.” At that point, he turned to the nurse and she booted them. Also, I have worked in high schools that have had students who are considering a career in medicine and the high school students watched surgeries. Also, I gave a few other examples.

Doctors and nurses in training programs, to me, is very separate from the other stuff I described. i am only speaking about the other stuff that is BS.

InklingBooks

I agree that something needs to be done. Indeed, I’ve been trying to get more done about a closely related issue myself.

When I was one of the few males on the nursing staff of a major children’s hospital, I faced similar issues with exams, particularly when I worked on the adolescent unit. Who were the worst offenders when the patient was a teen girl? Always the female residents and nurses. I had to be the one who excused myself and slipped away.
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One afternoon, I was taking care of a girl in the far corner of a four-bed room, when the speciality nurse who took care of central lines said something to me. I turned around to find that the robe of a girl of about fifteen was dropped to her waist, leaving her topless. “Why did you do this?” I thought to myself. “The girl has lost her left arm to bone cancer. The last thing she needs is for me to look at her.” I could tell from the frightened look on the girl’s face, that she’d been nervous about having me even in the same room and certainly didn’t appreciate having my attention being turned to her. I turned around quickly and stalled my care of the other girl until that nurse left.

I knew what was going on and in one sense it was harmless, much like shadowing. That speciality nurse was bored making her rounds and this patient was not talkative. The nurse wanted someone to talk with and started that conversation with me. I could have walked over and pretended to strike up a conversation about the procedure. That is what really scared that girl. Unprotected by her nurse, she felt vulnerable. My interest would have been nonsense. I’d spent 16 months on Hem-Onc assisting with the Hickman line care on small children and could have done the procedure myself. If I had done what that nurse wanted, what would that girl have done? From experience, I’d say she’d have been painfully embarrassed but said nothing. These adorable girls wanted to cooperate. That was their tragedy. They did not want to say no, least of all to a fellow woman.
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Later, when I began to write what are now two books on this topic, one for teen girls and one for hospital staff, I asked myself why female staff behaved that way. The answer came when I realized that as a guy I was just as casual about exposing our teen boys to female staff as they were about our girls. The reason, I suspect, lies in healthcare training, with its emphasis on learning not to be upset by blood, bodily fluids, or nakedness.

The first two come more easily than the third and nakedness is easiest with same-sex patients. Since a naked guy means nothing to me—I’d showered with other boys hundreds of times growing up—that was easily accepted and hence easily regarded as no big deal. For the female residents and nurses I worked with, that was equally true for our girls. For that central-line nurse, that topless girl meant nothing. She may have even regarded calling on me as showing how professional she was.
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I’d add another factor that’s of particular importance when shadowing brings strangers into an exam room. Trust is an important factor in such situations, and trust takes time. I learned that caring for those girls. I found them marvelously adaptable, but only after I won their trust.

At that hospital, the teen unit was filled each summer with orthopedic surgeries. For boys, that meant fixing sports and motorcycle injuries. For the girls it meant spinal fusions. Every other week would find me caring for a room with four helpless, barely clad girls who were far enough post-op that they needed no attention from their nurse. I was expected for provide all their care.

My first morning with with the first of those girls, I though, “Oh, my gosh. These girls will start acting like the boys.” Our teen boys, unhappy with their but-for-me female caregivers, did everything they could to avoid exposure in their hot room. They worn undies. They kept their gowns tucked in. They kept their sheets pulled up to their chins. These girls, accustomed to female caregivers, were the opposite in a room even hotter than the boys. No undies. Gowns flopping around. Sheets kicked down.

To my initial amazement, those girls and I got along marvelously. They stayed casual and comfortable while I worked hard to carry out my implicit promise to do everything in my power to lessen their embarrassment. That worked so well, I came to the conclusion that many those girls preferred me, who as a guy would be careful and even protective, to a woman who could be indifferent to their embarrassment. Just keep in mind that I had to work very hard to win their trust.

In short, the guys wanted to be in control of issues such as embarrassment. Denied that, they became sullen and uncooperative. The girls did not want to be in control, but sensing that the hospital could be a dangerous place for them, they wanted to feel that events were under control. That is why they found my offer of as much protection as I could offer comforting. My willingness to look out for them let them relax. I came to the conclusion that they sorted men into three categories: creeps who were a danger, wusses who would do them no good, and heroes, who’d look out for them They saw me as the third.

But keep in mind that the trust I established with them took time—more time that you will ever see in shadowing. Over and over again, for the first hour on our first day, the girls would be watching me. Then they’d conclude I could be trusted and relax. When they trusted, they really trusted.

You’ll need to read the book, Embarrass Less, to discover the practical ways I found to build their trust. Teen girls are extremely complicated, so I was perpetually being surprised by them. So the suggestions I make should work even better with other patients, particularly adults. I will admit that, as a guy, I wasn’t well set up to find out what works with teen boys. At best, I can offers suggestions and note that many of the ideas that worked with girls will also work with them.

–Michael W. Perry, author of Embarrass Less: A Practical Guide for Doctors, Nurses, Students and Hospitals

Ladyimacbeth

You can’t always avoid teaching hospitals. Every hospital and outpatient surgery center in the Houston area that I know of is a teaching hospital/facility even the ones that don’t advertise as such. We have so many different nursing schools, surgical tech programs, NP programs, etc in this city and surrounding area that they’re impossible to avoid.

David Penner

“People always say avoid teaching hospitals if you don’t want trainees, but I’m not real sure how patients go about that.” Indeed, this is a very good point. Many patients would like to avoid teaching hospitals, but their insurance sometimes dictates that they go to one. Moreover, Sloan Kettering happens to be a teaching hospital.

orthodoc

I’m sorry this patient feels put upon by having an entourage seeing him. But the idea that high school and college students have free run of the place is ridiculous. At our institution, anyone who wants to observe has to go through an attestation process that takes weeks.

And as much as it’s an inconvenience, teaching is part of what we do. He is at one of the premier oncologic facilities in the world, and it is a teaching facility.

David Penner

Where does it say in the article that high school students and college students “have free run of the place?” Moreover, it is very difficult for a patient to leave MSKCC should they have a rare and unusual cancer. Lenox Hill also has a poor oncology department, by the way.

5ny

Mt. Sinai is a teaching hospital.

5ny

There’s good medicine outside of Manhattan? are you telling me some of those magazine reviews are biased and/or not fair? (That was sarcasm in case it didn’t come across).

Ladyimacbeth

I would be very surprised if agreement to trainee involvement was not in the consent he signed; however, the point at which he verbalized no trainees at his appointment he revoked consent for that. Personally, I would never kick out trainees from my appointment at a known teaching hospital unless they were rude or something.

David Penner

“…Or it was a particularly sensitive issue.” This is a key point. But what doesn’t constitute a sensitive issue to the medical student, resident, or attending physician, may represent a very sensitive issue indeed to the patient.

Ladyimacbeth

I have a particularly sensitive medical issue that I’m dealing with, and it took me about a year to tell my doctor about it. I was that embarrassed, and I’m a nurse so you would think it would be easier for me, but it wasn’t. He told me he was going to refer me to another surgeon since it was out of his area, and I asked if there would be students involved. He said, “There might be a fellow, but you don’t have to see the fellow if you don’t want to.” I told him that I didn’t know what to do. I was worried that the doctor would be upset with me if I refused, but I just didn’t think I could discuss this with multiple people right now. He said, ” You’re not obligated to see the fellow. If they give you a hard time about it, you let me know, and I’ll refer you to someone else.” This is coming from a surgeon who is on faculty and works at a teaching hospital. He was very understanding about it.

I felt very conflicted, because I knew if patients had not allowed him to be involved when he was in medical school and residency and during his fellowship, that I wouldn’t get to have him as my doctor. At the same time, I knew if I had to talk to a bunch of people about this information I was probably going to not go or go and withhold information. The doctors I dealt with were very nice and didn’t give me a hard time at all. Sloan Kettering is big enough that they can still train doctors even if a few patients decline trainees. It’s not going to wreck the system, and I think they should respect your wishes.

David Penner

Thanks very much for your comment. I empathize completely with your predicament, and agree 100% that coerced physician shadowing can constitute a health risk, due to the fact that many patients will not tell their doctor everything that is on their mind when unwanted interlopers are observing the session. I also agree that with MSKCC, Cornell, Mt Sinai, and Columbia they are so big that if a few patients were to periodically object to physician shadowing it cannot possibly cause any fundamental harm to the education of medical students, residents, and fellows. Best regards, David

Ladyimacbeth

At appointments, I’ve always been asked before a physician brought in a medical student. However, when I was in my early twenties I was a patient at an ER and a physician came in with a whole group of people in white coats. I had no idea about teaching hospitals or how they operate at that point in time. I was scared to death. All I knew was that a bunch of doctors in white coats were lined up staring at me, and I thought that meant I was doomed. They were probably medical students, but I would have had no knowledge at that time what short white coats meant if that’s what they were wearing. White coat to me meant doctor. I’m sure they had trainee involvement in the consent I signed, but I was really sick and probably didn’t read it that closely. I don’t fault them for how they handled it, but I do see how it can feel scary and overwhelming to patients. I think sometimes that’s easy to forget.

5ny

I agree with you on the med students and other relevant rising professionals. I’m a counselor so I started my career shadowing and learning from sitting with counselors while dealing with students’ heavy, personal stuff. I now train others sometimes too. We definitely respect people’s privacy and dignity and have ways to do it. I have had students tell me they don’t want an observer and I absolutely honored that. I am referring to some places that seem to have a loose culture. I have a lot of exposure to a lot of stuff and I have seen some “interesting” things. Quite frankly, I don’t care if someone is watching for voueristic reasons as long as the patient/client made informed consent. And, in some cases, it may even be a good thing. Look up “dr pimple popper.” She gives a huge price break for patients to go on her YouTube channel. They get great quality dermatology care from a highly trained, excellent physician for free or low cost. People contact her all the time to go on. To me, it’s all about how it’s handled.

Markus

Thank you for this contribution. We doctors know that we exist to serve, and sometimes need to be reminded of the importance of the patient’s dignity.

Sounds like you have had a lot of medical care. Please accept my best wishes for your health.

David Penner

Thanks very much for your comment. Finally, someone with some common sense. At MSKCC and Cornell they never ask for the patient’s consent, and the shadowing continues even if the patient repeatedly voices their objections. Second grader ethics dictates that this is unethical and morally wrong.

David Penner

Not true: I was lying down and in bed, and she ripped the curtain open without knocking.

David Penner

Patients don’t “choose to get care” at MSKCC, they go there because they have cancer, and should they have something very rare MSKCC in many respects constitutes the only game in town. I don’t believe that physician shadowing should be banned. All I ask for is that the patient have the right to say no.

David Penner

Patients have a fundamental and inalienable right to privacy. Nonconsensual physician shadowing denies them this right, so who’s whining? Sloan Kettering is the only game in town for a New Yorker with a rare and unusual cancer. And it also happens to be a teaching hospital.

David Penner

As I indicated in the article: coerced physician shadowing may strike medical students, residents, and attending physicians as perfectly harmless, but should they be the patient with a serious medical condition and on the receiving end of this, they might be forced to look at the practice in an altogether different light. Would you want other people observing your doctor’s visit if you had breast cancer or ovarian cancer, for instance?

David Penner

Thanks for your comment. I agree.

David Penner

As you are clearly an advocate of nonconsensual physician shadowing, who’s the one who feels they are entitled?

Observer

Funny, I read the article thinking the writer was overstating the issue but with one fell swoop your response proved he wasn’t. Terribly sad.

5ny

Thanks for sharing.

David Penner

Thanks very much for your comment.

Ladyimacbeth

I think Baylor has a program like that, too. I’m going to hope Baylor spells it out clearly in their consent. They should. It needs to say high school student.

Ladyimacbeth

Thanks for clarifying that.

DebRN

This is a very valid description of the horror of non-medical people to the practices and habits of those inside anything medical. I am second career RN. I remember being shocked that there were people on the earth that actually noticed and remembered the last time they had a bowel movement. Size and color was not something I ever thought about. and it goes on to the eight people that walked in on me as I had my firstborn. Yes, I remember the feeling like I used to be modest. The author is correct. We often totally ignore the sensibilities of our patients. He is not wrong. It’s his perspective. Honor it.

David Penner

I didn’t say that patients have no choice in where to get treatment in NYC. What I said was that if they happen to have something very rare, many patients have little choice but to go to Memorial. If a patient had a common breast cancer, ovarian cancer, lymphoma, or leukemia it would not be difficult for the patient to get treatment at one of the other medical institutions.

David Penner

I’m objecting to coerced physician shadowing during a doctor’s visit – not to a team being involved in your care while being hospitalized.

Markus

Mr. Penner has spent a lot of time at Sloan-Kettering. This is a great institution doing very important things. I was an oncologist for many years. I saw many patients who were nearly naked except for a gown addressing cancer, which implies the real potential for death, pain, and suffering, and cancer treatment, which implies surgery, loss of body parts, nausea, fatigue, and alopecia. If some of them were not concerned about the future of medical education at that point in their life, I was willing to cut them some slack.
Soon it will be Thanksgiving. Some of my relatives will say things that I know are wrong. I will not confront them. I will bow my head grateful that I am not on a guerney with a bunch of medical students hanging around.

David Penner

And it sounds to me like you could not care less about the privacy, dignity, and emotional well being of your patients, which actually proves the very thesis of the article.